Session 13: Foot/Ankle and Trauma
09:00 - 10:00
Chair: Morten S Larsen and Ellen H-Petersen
Mette Frank Fenger1, Per Hviid Gundtoft2, Nanna Rolving1, Louise Mortensen1
1. Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital
2. Department of Orthopaedics, Aarhus University Hospital
Background: Treatment strategies for Achilles Tendon Rupture
varies considerably. At Aarhus University Hospital,
patients treated conservatively for achilles tendon
ruptures follow a restrictive regime with
immobilization for 11 weeks with late weight bearing
(after 10 weeks) and no motion of the ankle during
the treatment period.
Aim: To test the following hypothesis. A restrictive regime
for Achilles Tendon Ruptures result in:
1. Low rate of re-rupture
2. Better Achilles Tendon Rupture Score (ATRS),
due to smaller risk of elongation.
Materials and Methods: This was a questionnaire-based cross-sectional
cohort study including patients with
conservatively treated Achilles tendon rupture
treated at Aarhus University Hospital between
January 1, 2020 and July 31, 2022. A
questionnaire including the ATRS was sent
electronically to patients treated conservatively at
AUH within the past 24 months. Additionally,
patients were asked about reruptures, non-
healed tendons, deep venous thrombosis and
ATRS scores were compared to data from
Danish Achilles Database (DADB), which
included patients, who follow a more liberal
Results: Out of the 110 patients that received a questionnaire
100 responded. 83% were male and mean age was
55.6. The cohort was divided into three groups
based on time from Rupture to questionnaire: group
1 (6-12 months) consisted of 36 patients, group 2
(12-24 months) consisted of 30 patients, and group
3 (>24 months) consisted of 34 patients.
The mean ATRS scores were 49.0 in Group 1, 48.7
in Group 2, and 60.9 in Group 3. In DADB scores for
similar patient groups were found to be 48.7, 57.7
Four patients (4%) had a rerupture, four patients (4
%) had a non-healed achilles tendons, and four (4%)
patients experienced a DVT.
Interpretation / Conclusion: Assuming a minimal clinical important difference of 8
points on ATRS, we found no benefits in regards to
neither ATRS scores nor reruptures between our
study populations with a restrictive regime compared
to group with a less restrictive regime.
Mick Nielsen1, Jens Kurt Johansen2, Anna Kathrine Pramming3, Jeannette Østergaard Penny4
1. Department of Orthopaedic, University Hospital Zealand;
2. Department of Orthopaedics Copenhagen university hospital Hvidovre;
3. Department of Orthopaedic, University Hospital Zealand;
4. Department of Orthopaedic, University Hospital Zealand;
Background: The European foot and Ankle Society has
developed the 6 question EFAS score, as a
common European Patient reported outcome
measures (PROM) covering patients with foot
and ankle pathologies.
Aim: To translate and adapt the EFAS score into
Danish. Furthermore to perform a validation,
reliability and responsiveness testing of the new
Materials and Methods: Translation and adaptation in accordance with
guidelines from Beaton et. al. 2000
We aimed for 100 foot and ankle patients, 50 of
those as test-retest. Control group of 70 foot-
healthy individuals was planned.
Patients filled out pre- and 6 months post-
surgery evaluation of the EFAS-DK score.
Statistics: Validity: Floor, ceiling effect, Effect
size (ES) EFAS-DK more than 0.8. and large
difference between patient and control was
Reliability: precision, test-re-test ICC,
Measurement error and smallest detectable
Responsiveness: effect size and minimal
important change (MIC).
Interpretability: SDCResults: No major challenges were encountered during
the translation process.
We included 123 patients, 96 of those
completed the scores. Females/male: 64/32,
age mean/median: 58/59, 20 to 85 years. 47
completed the test-retest.
66 controls included, age mean/median 51/52
(23-79). 45 returned the 6 months evaluation.
EFAS-DK mean(SD) range. pre-operative:
8,5(5,4) 0 to 24, 6 months post-op: 14,0(5,3) 1
to 24, Controls baseline: 22,8 (1,8)17 to 24.
Mean changes in total EFAS-DK score pre-to-
post-op was 5,5. test-re-test: 0,1 Controls -0,5.
Floor/ceiling effect for preoperative patients 2/96
and 1/96, for controls 0/45 and 27/45. Effect
size EFAS-DK patient: 1,0 Effect size EFAS-DK
Test-retest ICC; 0.93, Measurement error 1,37
and SDC: 3,2
MIC:1,5 EFAS points.
Interpretation / Conclusion: The ES is large for patients and low for controls.
Low floor and ceiling effect. The ICC
demonstrates excellent reliability. As for
responsiveness the SDC by the patient was
higher than the MIC which may reflect a
weakness in our anchor questions. Overall, the
EFAS-DK score seems to reliably identify
relevant changes. Half the patients felt a large
improvement in their foot, but as a general their
operated foot are far from normal at 6 months
Michael Rindom Krogsgaard1, Henrik Palm1, Kenneth Obionu1, Yvette Astrup Cramer1, Naja Bjørslev Lange1, Tobias Haak1, Christian Dippmann1
Department of Orthopedic Surgery, Bispebjerg and Frederiksberg University
Hospital, Copenhagen, Denmark.
Background: 40 % of patients with chronic ankle instability
have pathology of the deltoid ligament (DL), and
DL reconstruction (DLR) can be indicated. DL
instability can lead to ankle OA. Series after
DLR are small.
Aim: Long-term follow-up of DLR in a large group of
Materials and Methods: During the primary operation an ankle
arthroscopy had been performed to visualize
the DL, and other relevant pathologies were
also treated surgically.
503 consecutive patients (524 ankles) who
had a DLR 2010-2018 were due to patient
complaints invited in sept-nov. 2021 to
answer postoperative period questions,
complete the questionnaire FAAM and a
ROM (range of motion) scale, and answer a
number of anchor questions – and were
offered optional physical control.
On Jan 12, 2022 a TV-program and
newspaper articles on this cohort was
alleging the possibility of malpractice. For
risk of bias, it was decided to close the link to
collection of patient-responses the day after.
Results: 342 had a history of a trauma to the ankle
and 105 had previous ankle surgery. In 447
the operating foot surgeon evaluated the
MRI as showing signs of a pathology to the
DL. 421 feet (80%) had procedures in
addition to DLR.
A total of 269 (53.8%) patients responded to
the invitation prior to the release of critical
press coverage. 11 indicated that they did
not wish to participate. For 71% the
operation solved their ankle-problems, for 11
% it made no change and for 19 % the
condition became worse. 163 (63 %) were
satisfied with surgery and 87 (34 %) were
dissatisfied. 63 % would repeat the
operation, 11 % might choose operation and
21 % would not. 67 % had pain in the ankle
during the past week, and 50 % were not
able to run. The mean score of the FAAM
ADL scale was 44 (vs. 58 in a group of
healthy persons), and the FAAM Sport scale
13 (vs. 24). Mean ADL ability (scale 0-100)
was 72 (vs. 89) and mean sports ability 53
Interpretation / Conclusion: The relatively high degree of satisfaction in our
cohort despite suboptimal clinical results (50 %
are unable to run) probably reflects the complex
nature of pathology in the DL insufficient ankle.
There is a need for structured scientific evidence
to establish principles for treatment.
Bjørn Nedergaard1,2, Torben Stryhn1,2, Bjarke Viberg1,2
1. Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital
2. Department of Orthopaedic Surgery and Traumatology, Odense University
Background: New generation Nitinol staples are easily
implanted and are increasingly used in foot and
ankle surgery. However, data regarding
complications and reoperation rates when
compared to standard treatment with screws and
plates are scarce.
Aim: To assess reoperation rates after fixation with
Nitinol staples in comparison to screws and
plates in arthrodeses or osteotomies (A/O) of the
Materials and Methods: This is a single center retrospective cohort
study. Patients who had A/O with Nitinol
staples, screws or plates in their feet from
01.08.2017 to 14.10.2020 were identified
through the hospitals administrative
database. Choice of implant was by the
surgeon´s discretion. A/Os where a choice
between staples, screws or plates was not
relevant were excluded (e.g. subtalar
arthrodesis). Patient files and x-rays were
reviewed by two experienced foot and ankle-
surgeons for surgical details and baseline
clinical data. One year follow-up was
conducted for reoperations. Descriptive
statistics were applied.
Results: There were 395 patients with 486 A/O of the
feet. Median age was 60 years (range 16-83)
and 68% were females. The majority had an
ASA score of 1 or 2 (83%), 7% had diabetes,
18% were smokers and 3% had alcohol
There were 288 A/O treated with staples and
11.1% had a reoperation. Nonunions
represented 3.1% while 5.9% were hardware
removal. There were 73 A/O with screws and
20.5% had a reoperation. Nonunions
represented 4.1% while 13.7% were
hardware removal. There were 125 A/O with
plates and 28.0% had a reoperation.
Nonunions represented 8.0% while 16.0%
were hardware removal.
When assessing single joints, we observed
reoperation rates of the 1st MTP-joint due to
nonunion were 3.6% for staples, 4.2% for
screws and 8.8% for plates. Reoperation
rates of the 1st TMT-joint due to nonunion
were 2.6% for staples and 7.5% for plates.
Only 1 patient had surgery with screws only
and no reoperation was observed.
Interpretation / Conclusion: A/Os in the feet with Nitinol staples seem to have
few complications and low reoperation rates in
comparison to plates and screws. Nitinol staples
could be a future golden standard implant when
performing arthrodeses and osteotomies in the
Per Hviid Gundtoft1,5, Julie Ladeby Erichsen2, Mads Terndrup3, Lauritz Walsøe1, Lasse Pedersen2, Bjarke Viberg2,4,5, Alice Ørts2,4, Charlotte Abrahamsen5,6
1: Department of Orthopaedic Surgery, Aarhus University Hospital
2: Department of Orthopaedic Surgery, Odense University Hospital
3: Department of Orthopaedic Surgery, Hvidovre Hospital
4: Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
5: Department of Orthopaedic Surgery, Lillebaelt Hospital - Kolding,
6: Department of Regional Health Research, University of Southern Denmark
Background: In research studies of patients with ankle fractures
several different patient reported outcome measures
(PROM) have been used but few studies have
Aim: To compare patient preferences and psychometric
properties of the Manchester Oxford Foot
Questionnaire (MOXFQ), the Self-reported Foot and
Ankle Score (SEFAS), the Olerud Molander Ankle
Score (OMAS), and the Forgotten Joint Score (FJS)
in adults with ankle fractures.
Materials and Methods: Patients with a surgically or non-surgically
treated ankle fracture at three hospitals were
included between 01.11.2018 to 31.08.2020.
Patients received all four questionnaires 6-, 12-,
14-, 24-, 52-, and 104-weeks following the ankle
fracture. Only fully completed questionnaires
were included in the analysis.
According to COSMIN guidelines, statistical tests
were performed to assess structural validity,
construct validity and reliability. Furthermore,
floor- and ceiling effects were assessed at all
Content validity was assessed using cognitive
interviews of nine patients, who were also asked
to grade all four PROMs in order of priority.
Results: Each PROM was fully completed by 135 patients
12 weeks post-injury and by 111 at 14 weeks
When performing Confirmatory Factor Analysis,
MOXFQ showed best model fit (CFI 0.946; TLI
0.936; RMSEA 0.08). When testing construct
validity, all hypotheses were accepted except
one as OMAS and FJS had a correlation of <0.7.
All PROMs had an almost perfect test-retest
reliability for the total score and for all domains.
Interclass Correlation Coefficient 2.1 were
between 0.81 to 0.91. Internal consistency
measured by Cronbach's alpha ranged between
0.76 to 0.95 for the total scores and the domains.
Only MOXFQ had an alpha of 0.69 for the
domain social, which is below acceptable. The
OMAS showed ceiling effect at 52-weeks and
MOXFQ floor-effect at 104-weeks.
Eight patients out of nine expressed that MOXFQ
were the best or second-best at assessing their
symptoms. Six patients scored SEFAS best or
Interpretation / Conclusion: All PROMs performed well in the psychometric
evaluation. Patients rated MOXFQ and SEFAS
highest. We recommend that MOXFQ should be
used in future ankle fracture studies.
Christian Grundtvig Refstrup Rasmussen1, Rasmus Elsøe1, Christian Pedersen1, Peter Larsen2
1. Department of Orthopaedics, Aalborg University Hospital;
2. Department of Physiotherapy, Aalborg University Hospital
Background: Ankle fractures are very common injuries. Following
surgical treatment, inpatient care for 4-10 days is
common. Several studies have reported that
outpatient surgical treatment of ankle fractures is
safe. However, the literature lacks high quality
randomised controlled trials comparing inpatients
and outpatient care.
Aim: The aim of this study was to investigate the
feasibility of outpatient care for selected surgically
managed ankle fractures and the setup of a
randomized controlled trail comparing in- and
outpatient care of ankle fractures with regard to
patient reported outcome, patient satisfaction,
adverse events, pain, function and healing.
Materials and Methods: This study is a proof-of-concept study as part of
a non-inferiority randomized control design to
compare in- and outpatient care of ankle
fractures. Included were adult patients (>= 18
years), stable ankle fractures necessitating
surgical treatment and able to ambulate with
walking aid and perform adequate ADL at home.
Feasibility was based on two questions regarding
patients experience with the treatment and the
absence of any serious adverse events. Clinical
results were obtained at 2 days, 2, 6 and 12
weeks and included pain, range of ankle motion
(ROM), healing, Foot and Ankle Outcome Score
(FAOS), European Quality of life 5 Dimensions
questionnaire, (EQ5D-5L), workforce and Tegner
Activity level. Adverse events were reported
throughout the study.
Results: A total of 76 patients were accessed for eligibility
and 22 patients were included. 49 patients were
excluded, and 6 patients did not want to participate.
The most common reasons for exclusion were: 22
patients were not able to ambulate with walking aid
and perform adequate ADL at home and 15 patients
were not stable in preoperative cast. The median
age was 48.6 with and range from 18 to 77. Female
sex represents 52%. Patient reported experience
and satisfaction response completeness: 2 weeks –
17/22, 6 weeks 17/22 and 12 weeks 19/22.
Interpretation / Conclusion: Results indicate that a full RCT comparing in- and
outpatient care of ankle fractures is feasible without
adjustments of the protocol. High completeness in
the planned follow-up procedure was observed.
Louise Thuren Jørgensen 1, Christian Cavallius2, Nikoline Møller Lynnerup3, Ole Brink4
1. Ortopædkirurgisk afd. M, Bispebjerg Hospital.
2. Ortopædkirurgisk afd. O, Odense Universitetshospital.
3. Ortopædkirurgisk afdeling. Herlev Hospital.
4. Ortopædkirurgisk afdeling. Århus Universitetshospital.
Background: Immobilization due to ankle fracture increases the risk of venous thromboembolism (VTE) including deep vein thrombosis (DVT) and pulmonary embolism (PE). There’s no national Danish guideline about the use of thromboprophylaxis with low molecular weight Heparin (LMWH) when immobilizing patients due to ankle fracture, and current international guidelines disagree whether or not to use thromboprophylaxis.
Aim: The purpose of this short clinical guideline is to review current literature on the subject and to offer support when deciding for or against thromboprophylaxis when immobilizing patients with a brace or cast due to ankle fracture.
Materials and Methods: A systematic search of relevant literature was conducted on Pubmed, Embase and Cochrane on March 9th, 2023. The evidence was rated by standardized forms (AMSTAR2, Cochrane Risk of Bias-tool and GRADE).
Results:From a total of 545 studies, 441 were excluded on titles and abstracts, and 97 studies were excluded after reading full text by at least two of the authors. Further two studies were excluded due to wrong study design, and one was excluded due to a low score on AMSTAR2. Of the remaining four studies, two were metaanalyses, and two RCTs that already were included in the two meta analyses.
One meta-analysis showed significant lower incidence of asymptomatic DVTs, when using LMWH compared to placebo or no treatment (OR=0,48 (0,33;0,7)). The other meta-analysis showed significant lower incidence of symptomatic DVTs, when using LMWH compared to placebo or no treatment (OR 0,29 (0,09;0,95)).
No clear differences were found between the LMWH and control groups for PE. Major adverse events were rare.
Interpretation / Conclusion: Low-quality evidence showed that the use of LMWH reduced the incidence of DVT when immobilizing the lower limb due to ankle fracture, when compared with no prophylaxis or placebo. Low-quality evidence showed no clear differences in PE rates. The quality of evidence was reduced to very low because of heterogenicity in inclusion criteria, treatment protocols and measurement of outcome in the studies included in the two metaanalyses, resulting in a high risk of bias.